Dosing Modifications

Depression

7.5 mg/day PO qHS; increase by 7.5-15 mg/day no more frequently than q1-2Weeks; not to exceed 45 mg/day

Alzheimer Dementia-related Depression

7.5 mg/day PO qHS; increase by 7.5-15 mg/day no more frequently than q1-2Weeks; not to exceed 60 mg/day

Dosing Considerations

The elderly have reduced clearance of mirtazapine and, as a result, may have increased plasma levels of the drug

Use with caution

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Interactions

Interaction Checker

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Adverse Effects

>10%

Somnolence (54%)

Weight gain (>7% increase in <49% of pediatric patients)

Xerostomia (25%)

Increased appetite (17%)

Constipation (13%)

1-10%

Asthenia (8%)

Weakness (8%)

Weight gain (>7% increase in 8% of adults)

Dizziness (7%)

Serum TGs increased (6%)

Dream disorder (4%)

Disturbance in thinking (3%)

ALT increased (2%)

Peripheral edema (2%)

Myalgia (2%)

Confusion (2%)

Urinary frequency (2%)

Tremor (2%)

Back pain (2%)

Dyspnea (1%)

<1%

Mania (0.2%)

Grand mal seizure (less than 0.1%)

Frequency Not Defined

Depression exacerbation

Status epilepticus

Suicidal thoughts, suicide (rare)

Agranulocytosis

Neutropenia

Postmarketing Reports

Severe skin reactions

Stevens-Johnson syndrome

Bullous dermatitis

Erythema multiforme

Toxic epidermal necrolysis

Increased creatine kinase blood levels

Rhabdomyolysis

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Warnings

Black Box Warnings

In short-term studies, antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults (<24 years) taking
antidepressants for major depressive disorders and other psychiatric illnesses

This
increase was not seen in patients >24 years

A slight decrease in suicidal
thinking was seen in adults >65 years

In children and young adults, risks must be weighed against the benefits of taking antidepressants

Patients should be monitored closely for changes in behavior, clinical worsening, and suicidal tendencies

This should
be done during the initial 1-2 months of therapy and dosage adjustments; the patient’s
family should communicate any abrupt changes in behavior to the healthcare provider

Worsening behavior and suicidal tendencies that are not part of the presenting
symptoms may require discontinuation of therapy

This drug is not approved for use in
pediatric patients

Contraindications

Hypersensitivity

Within 14 days of administration of MAOIs (serotonin syndrome)

Patients receiving linezolid or methylene blue IV

Cautions

Start slowly in hepatic or renal dysfunction and in the elderly

Clinical worsening and suicidal ideation may occur despite medication

Rare reports of serotonin syndrome, particularly when coadministered with other serotonergic drugs

Akathisia and psychomotor restlessness associated with antidepressant use

Rare reports of hyponatremia; caution in elderly or if coadministered with other drug known to cause hyponatremia

Risk for potentially life-threatening serotonin syndrome and neuroleptic malignant syndrome-like reactions has been reported with SSRIs, SNRIs, MAOIs, and other serotonergic drugs used as monotherapy, but particularly with concomitant use of the following agents: serotonergic drugs (including triptans), drugs that impair metabolism of serotonin (including MAOIs), antipsychotics, dopamine antagonists, and nonpsychiatric MAOIs (eg, linezolid, IV methylene blue)

May cause anticholinergic effects; use with caution in patients with xerostomia, BPH, paralytic ileus, or decreased intestinal motility

Risk of mydriasis; may trigger angle closure attack in patients with angle closure glaucoma with anatomically narrow angles without a patent iridectomy

May increase serum triglycerides and cholesterol levels

May cause orthostatic hypotension (low risk); use with caution in patients at risk

Sexual dysfunction may occur (incidence lower compared to SSRIs)

May worsen psychosis in some patients or precipitate mania or hypomania in patients with bipolar disorder

Use with caution in patients with history of seizures, head trauma, alcoholism, brain damage, and patients on medictions that may lower seizure treshold

QTc prolongation, ventricular fibrillation, and torsade de pointes rarely reported; use caution in patients with history of QTc prolongation, receiving QTc prolongent agents concomitantly, or with cardiovascular disease

Discontinue therapy if neutropenia/agrunolocytosis occur

May cause CNS depression, which may impair abilities to perform hazardous tasks that require mental alertness

May increase serum cholesterol and triglyceride levels

May increase appetite and cause weight gain

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Pregnancy & Lactation

Pregnancy category: C

Lactation: Avoid

Pregnancy Categories

A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

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The above information is provided for general
informational and educational purposes only. Individual plans may vary
and formulary information changes. Contact the applicable plan
provider for the most current information.

View explanations for tiers and
restrictions

Tier

Description

1

This drug is available at the lowest co-pay. Most
commonly, these are generic drugs.

2

This drug is available at a middle level co-pay. Most
commonly, these are "preferred" (on formulary) brand drugs.

3

This drug is available at a higher level co-pay. Most
commonly, these are "non-preferred" brand drugs.

4

This drug is available at a higher level co-pay. Most
commonly, these are "non-preferred" brand drugs or specialty
prescription products.

5

This drug is available at a higher level co-pay. Most
commonly, these are "non-preferred" brand drugs or specialty
prescription products.

6

This drug is available at a higher level co-pay. Most
commonly, these are "non-preferred" brand drugs or specialty
prescription products.

NC

NOT COVERED – Drugs that are not
covered by the plan.

Code

Definition

PA

Prior Authorization Drugs that
require prior authorization. This restriction requires that
specific clinical criteria be met prior to the approval of the
prescription.

QL

Quantity Limits Drugs that
have quantity limits associated with each prescription. This
restriction typically limits the quantity of the drug that will
be covered.

ST

Step Therapy Drugs that have
step therapy associated with each prescription. This restriction
typically requires that certain criteria be met prior to
approval for the prescription.

OR

Other Restrictions Drugs that
have restrictions other than prior authorization, quantity
limits, and step therapy associated with each prescription.